Failure to Timely Update Care Plan for Resident with Dementia and Behavioral Issues
Penalty
Summary
The facility failed to timely update the care plan for a resident with dementia and mood disturbance, who exhibited physically abusive and exit-seeking behaviors. Despite multiple documented incidents, including verbal aggression, wandering, attempts to leave the building, and increased agitation, the care plan was not revised to include new interventions such as fifteen-minute checks, medication changes, or relocation to a secured dementia unit. Progress and social service notes indicated that staff and the interdisciplinary team (IDT) responded to these behaviors with various interventions and meetings, but these changes were not reflected in the resident's official care plan. The resident's clinical record showed ongoing behavioral issues and a pattern of staff attempting different non-pharmacological and pharmacological interventions, including increased monitoring and environmental changes. However, the care plan remained largely unchanged and did not document the new strategies implemented in response to the resident's evolving needs. Interviews with facility leadership confirmed that care plans were generalized and not sufficiently individualized to reflect the resident's specific behavioral interventions.